Table 2.

Description of articles addressing virtual care and health equity during the COVID-19 pandemic.

Reference	Framing	Issues raised	Recommendations
Das and Gonzalez, 2020 [23]	Health care equity (equity in access to health services) is especially important to consider during COVID-19.	Access to technology (phones, phone lines, devices for virtual care) Digital literacy Cultural and linguistic issues Mistrust in health care systems	Select phone over video for certain populations Offer telemedicine outside of usual business hours Identify reimbursement models with insurers for underserved or marginalized patients Promote virtual widely to grow awareness among underserved or marginalized communities Partner with community organizations to provide peer-led technical support
Beaunoyer et al, 2020 [24]	Digital inequalities as a determinant of health. Suggest that digital inequalities enhance susceptibility to contracting COVID-19.	Outline 4 proximal influences on whether people can use technology: Technical means (the quality of the equipment that one can access, both in terms of hardware and software as well as the power and reliability of internet connection) Autonomy of use (the location where technology is accessed, and perceived freedom to use it as wanted) Social support networks (assistance from other experienced users) Experience (time dimension enabling people to be familiar enough with the technology to retain benefits from its use)	Increase access to connected devices Increase digital literacy (eg, educational programs) Increase access to relevant social support (eg, social support phone lines, user-friendly apps, etc) Increase diffusion of public health messages (eg, increase redundancy of important messaging) Increase control over quality of messaging Increase understandability of messaging Increase acceptability of messaging
Crawford and Serhal, 2020 [12]	Health equity; digital health innovation should not exacerbate existing health inequities during COVID-19.	Links between broader social determinants of health and the digital determinants of health Access to digital resources Use of digital resources for health seeking Digital health literacy Beliefs about potential for digital health to be helpful or harmful Values and cultural norms or preferences for digital resources Integration of digital resources into community and health infrastructure	Equal access to digital health leading to equal outcomes across identity groups Health providers trained to have competencies to provide equitable digital health care Measurement of equity-related outcomes Quality improvement focused on equity-related outcomes Involvement of people from marginalized groups in leadership, health professions, co-design, and data stewardship
Rodriguez et al, 2020 [15]	Digital divide should be considered in the implementation of recent policy (The 21st Century Cures Act)	Uptake of digital health tools is lower among marginalized populations Digital health tools have not been designed for marginalized populations	Promote access to broadband internet and digital devices Develop programs to promote digital health literacy Vendors should use inclusive design strategies Adopting organizations should embed equity in newly established digital services Offer digital services to all patients Government policy should clarify standards for design of digital health innovations
Eberly et al, 2020 [14]	Empirical evaluation of difference between those who completed scheduled telemedicine visits and those who did not. Vulnerable patients may have increased barriers to telemedicine care.	Findings highlight unique challenges faced by women, those who were non–English speaking, and poorer patients	Interpretation services Translation of instructions Improve distribution of video-enabling devices to those unable to afford them Payment parity between insurers for video and audio visits
Nouri et al, 2020 [13]	Health equity; relying on telemedicine risks further exacerbating inequities as certain patient groups may experience less access to care.	Reduced access to digital health among people in the following groups: Rural populations Older adults Racial/ethnic minority populations Low socioeconomic status Limited health literacy Limited English proficiency	Identify disparities in access Explore potential improvements related directly to existing disparities in access Mitigate digital literacy and resource barriers Remove health system barriers (offer video visits to every patient, ensure interpreter services, screen for patient barriers to video visits, offer telephone visits if video visits unavailable) Increase system leadership awareness of barriers to telemedicine Advocate changes to support equitable access (enable access to low-cost or free internet, pay parity for telephone and video visits from all payers)
Gray et al, 2020 [25]	Prevent exacerbation of health disparities	Adverse consequences of the digital divide most prominently affect low-income, rural, disabled, racial/ethnic minority, and older adult populations Sociocultural barriers to digital health: limited electronic skills, low health literacy, disability, low income, and limited English proficiency Structural barriers to digital health: geographic isolation, broadband capacity, and technical hardware Lack of touch also negatively affects communication with patients	Expand broadband access Accommodate language, literacy, and disability Provide telehealth literacy training Engage community health workers Promote digital empathy and webside manner
Ramsetty and Adams, 2020 [26]	Disparities in access to telemedicine care among vulnerable patients.	Lack of access to internet Cultural expectations of technology and its use in health care Mistrust of health care or of technology Literacy regarding digital technologies and digital health Lack of access to relevant digital devices Health care systems favoring newer, more expensive technologies	Combine technology and in-person visits, enabling care for people without access to technology (focused primarily on raising awareness about the digital divide during the pandemic)
Egan, 2020 [27]	An explicit focus on informal carers (known as unpaid caregivers in other contexts) and the challenges of engaging carers via digital health and virtual care.	A large proportion of carers have some form of disability A large proportion of carers use digital technologies Currently very few digital or virtual care initiatives are targeted toward caregivers in particular	Attention should be paid to providing virtual or digital resources specifically for caregivers
Friis-Healy et al, 2020 [28]	Increasing reliance on digital technologies risks exacerbating the digital divide, with adverse consequences on mental and behavioral health, especially of racialized populations.	Systemic racism and the pandemic are exacerbating mental health concerns for racialized communities, especially Black and Indigenous communities	Invest in building real-world evidence for digital mental health Educate providers and consumers about choice and safety of digital mental health Prioritize adaptive digital mental health content, allowing tailoring to particular communities Build digital mental health apps and services for diverse patient populations Build trust by evaluating and vetting in transparent ways
Jackson et al, 2020 [29]	The postpandemic future will see digital technologies dominating health spaces. Public health goal setting must attend to equity in digital health, particularly related to the vision of Health People 2030.	Persistent disparities exist in relation to internet access, using technology to manage health, online health information seeking, and health literacy	Ensure that health literacy and digital health objectives are a part of Healthy People 2030 Enhance data collection on digital health disparities Convene to critically discuss ideal objectives and strategies to achieve them
Kassamali et al, 2020 [30]	Policies enhancing access to telehealth services will expire at the end of the pandemic, but should persist for the sake of enhancing health equity.	Minoritized communities have had less access to health care during the pandemic Minoritized communities have been less able to shelter in place	Examine in detail how minoritized communities have adopted and engaged with telehealth services to inform equitable policy
Mike and Laroche, 2020 [31]	The pandemic has illustrated health inequities very clearly, and these extend to eye health as well. Short- and long-term actions are necessary.	Racism and structural inequalities are the causes of health inequities observed during the pandemic	More strongly incorporate telemedicine into eye care Advocate for policy changes that lead to insurance coverage for more people Take longitudinal action to address structural racism by encouraging cultural competence and holistic acceptance in medical education
Ortega et al, 2020 [32]	The pandemic has led to investments in telemedicine around the world. Specific policy considerations must be made to ensure telemedicine promotes health equity.	Inequitable access to telemedicine is driven by three main barriers: (1) disparities in access to broadband internet and related technology, (2) financial barriers to the reimbursement of telemedicine, and (3) lack of institutional commitment to equity in telemedicine	Policy must invest in expanding broadband internet access, enhance the availability of virtual care through reimbursement mechanisms, and clarify privacy and security requirements for commercially available platforms Hospitals should take on responsibility to enhance digital access and literacy
Wood et al, 2020 [33]	Many infectious diseases are disproportionately experienced by people from marginalized communities. The infectious disease community ought to invest in digital health equity.	Primary issues reducing access to virtual care are lack of technology, internet access, digital literacy, and private space in which to engage	Expanded reimbursement of telemedicine must continue after the pandemic Assess patient technical readiness. Provide just-in-time training to patients for access Provide instruction in preferred language Conduct a test to confirm capability Develop programs to offer digital devices to people who do not have access Offer language interpretation Design for various languages and cultural preferences Do not rely solely on electronic record–based portals for video visits Train clinical staff to consider equity when supporting patients virtually Track disparities in access and use disparities as a performance indicator